HESI LPN
HESI Fundamentals Exam
1. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?
- A. Teaching the client about the purpose of the medication
- B. Giving the medication at the administration time the provider prescribed
- C. Identifying the client’s medication allergies
- D. Documenting the client’s anxiety level
Correct answer: C
Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.
2. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The client returns from the post-anesthesia care unit crying but awake. Which approach is likely to be successful?
- A. Examine the mouth first
- B. Reassure the child
- C. Examine the mouth last
- D. Offer a pacifier
Correct answer: C
Rationale: In this scenario, it is crucial to prioritize the comfort of the child. By examining the mouth last, discomfort is minimized, and the child is given the opportunity to settle down. Choosing to examine the mouth first may escalate the distress of the child further. While reassuring the child is important, in this case, addressing the physical discomfort before providing emotional reassurance is more effective. Offering a pacifier may provide some comfort, but addressing the immediate physical discomfort by examining the mouth last is the most appropriate action to help the child settle down after the procedure.
3. How should the nurse transcribe the dosage of this medication on the client's medical record?
- A. 0.3 mg
- B. 0.3 mg
- C. 0.30 mg
- D. 3/10 mg
Correct answer: B
Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.
4. A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?
- A. Apply an ice pack to the client's back for 1 hour.
- B. Remove distractions from the client’s room.
- C. Instruct the client to take deep rhythmic breaths.
- D. Encourage the client to apply a heating pad for 2 hours at a time.
Correct answer: C
Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.
5. A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?
- A. Place the bladder of the cuff over the posterior aspect of the thigh
- B. Use a smaller cuff designed for lower extremities
- C. Place the cuff around the client's ankle
- D. Ensure the cuff is positioned above the knee
Correct answer: A
Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.
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